Incident investigation·December 13, 2022

This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Ruth Martinez to follow up on incident reported to Community Care Licensing. LPA arrived at facility greeted by receptionist and informed them of the visit. LPA met with Patricia Miller, Executive Director and explained the nature of the visit. Incident report dated 11/22/2022 for medication error on 11/20/2022 –11/21/2022 involving resident R1. Medication occurred by a discrepancy on pharmacies prescription indication. Prescription dosage was incorrect for resident as indicated Gabapentin 300mg when prescription should had been 100mg. Med tech failed to check mediation against MAR at facility. NOC shift nurse was checking medication and realized that medication dosage was incorrect per original prescription. Responsible party and PCP was notified. The following plan has been placed immediately: upon delivery of medication from pharmacy front desk staff will call facility nurse for review, nurse will cross check medication with MAR sheet and sign off pharmacy upon accuracy. Facility held training on same day of discovered error on six rights and medication error to all facility staff. No adverse effects were noted with resident and incident in question. Facility continues to aggressively monitor medication for accuracy for all residents. Since incident facility has had no further medication errors on site. LPA found that facility acted appropriately and in a timely manner to address the incident and all other immediate attention to incident in question. LPA did not observe any immediate and/or safety risks in or out of the facility. Based on the observation made during today's visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with Executive Director and a copy of this LIC809 report was provided and left at the facility.